U.S. patent number 10,485,555 [Application Number 14/876,142] was granted by the patent office on 2019-11-26 for bi-cruciate knee system.
This patent grant is currently assigned to Biomet Manufacturing, LLC. The grantee listed for this patent is Biomet Manufacturing, LLC. Invention is credited to Nathan Emick Belcher, Joshua B. Catanzarite, Bradley T. Durcholz, Robert Metzger, Audra C. Watson.
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United States Patent |
10,485,555 |
Metzger , et al. |
November 26, 2019 |
Bi-cruciate knee system
Abstract
An instrument set and related method for preparing a proximal
tibia during a bi-cruciate retaining procedure are disclosed. The
instrument set can include a tibial resection block, a cut guide,
and a locking arm. The tibial resection block can be configured to
be fixed to an anterior portion of the proximal tibia. The tibial
resection block can define a slot that extends in a medial-lateral
direction when the tibial resection block is fixed to the proximal
tibia. The cut guide can have a body, a medial arm, and a lateral
arm. A medial cut slot can be defined between the body and the
medial arm. A lateral cut slot can be defined between the body and
the lateral arm. The cut guide can further comprise a tongue
extending therefrom. The tongue can be configured to be received by
and slidably translate along the slot of the tibial resection
block.
Inventors: |
Metzger; Robert (Wakarusa,
IN), Belcher; Nathan Emick (Warsaw, IN), Watson; Audra
C. (Fort Wayne, IN), Durcholz; Bradley T. (Warsaw,
IN), Catanzarite; Joshua B. (Warsaw, IN) |
Applicant: |
Name |
City |
State |
Country |
Type |
Biomet Manufacturing, LLC |
Warsaw |
IN |
US |
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Assignee: |
Biomet Manufacturing, LLC
(Warsaw, IN)
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Family
ID: |
46147768 |
Appl.
No.: |
14/876,142 |
Filed: |
October 6, 2015 |
Prior Publication Data
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Document
Identifier |
Publication Date |
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US 20160045205 A1 |
Feb 18, 2016 |
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Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
Issue Date |
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13470630 |
May 14, 2012 |
9161761 |
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61486023 |
May 13, 2011 |
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61593521 |
Feb 1, 2012 |
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Current U.S.
Class: |
1/1 |
Current CPC
Class: |
A61F
2/4684 (20130101); A61B 17/157 (20130101); A61B
17/1764 (20130101); A61F 2/4657 (20130101); A61F
2/4637 (20130101); A61F 2/461 (20130101); A61F
2002/4681 (20130101); A61F 2002/4668 (20130101); A61B
17/154 (20130101); A61F 2002/4658 (20130101); A61F
2/3859 (20130101); A61F 2/389 (20130101); A61F
2002/4661 (20130101) |
Current International
Class: |
A61B
17/15 (20060101); A61B 17/17 (20060101); A61F
2/38 (20060101); A61F 2/46 (20060101) |
Field of
Search: |
;600/214,218-222
;269/3,6,95,166,246 ;606/86R-90,96-98,105,54-59,82 |
References Cited
[Referenced By]
U.S. Patent Documents
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102149337 |
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Aug 2011 |
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CN |
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JP |
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2018507074 |
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Mar 2018 |
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JP |
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WO-9729696 |
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Aug 1997 |
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WO |
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WO 2008091358 |
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Jul 2008 |
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WO |
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WO |
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WO-2013063386 |
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May 2013 |
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WO |
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WO-2016141274 |
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Sep 2016 |
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WO |
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|
Primary Examiner: Bates; David W
Assistant Examiner: Shirsat; Marcela I
Attorney, Agent or Firm: Schwegman Lundberg & Woessner,
P.A.
Parent Case Text
CROSS-REFERENCE TO RELATED APPLICATIONS
This application is a continuation of U.S. patent application Ser.
No. 13/470,630, filed on May 14, 2012, which claims the benefit of
U.S. Provisional Application Nos. 61/486,023, filed on May 13, 2011
and 61/593,521, filed on Feb. 1, 2012. The entire disclosures of
both of the above applications are incorporated herein by
reference.
Claims
What is claimed is:
1. An instrument set for preparing a proximal tibia during a
bi-cruciate retaining procedure, the instrument set comprising: a
tibial resection block configured to be fixed to an anterior
portion of the proximal tibia, the tibial resection block defining
a first slot that continuously extends in a medial-lateral
direction from a lateral portion of the proximal tibia to a medial
portion of the proximal tibia when the tibial resection block is
fixed to the proximal tibia, the first slot configured to act as a
guide for performing a proximal resection of both the medial
portion and the lateral portion of the proximal tibia; a vertical
cut guide configured to be received in and to slidably translate
along the first slot of the tibial resection block in the
medial-lateral direction, the vertical cut guide configured to
define both a medial slot for performing a first sagittal resection
of the medial portion of the proximal tibia and a lateral slot for
performing a second sagittal resection of the lateral portion of
the proximal tibia; and a gauge having a first portion configured
to be positioned on the medial portion and a second portion
configured to be positioned on the lateral portion of the proximal
tibia after the performing of the proximal resection, wherein the
gauge has indicia to determine if a slope of the medial portion
differs from a slope of the lateral portion.
2. The instrument set of claim 1, wherein the vertical cut guide is
configured such that the medial and lateral cut slots are open at a
proximal surface of the vertical cut guide.
3. The instrument set of claim 1, wherein the vertical cut guide is
configured such that the medial and lateral cut slots are each at
least partially closed by a wall at a proximal surface of the
vertical cut guide.
4. The instrument set of claim 1, wherein the medial and lateral
cut slots terminate at partial bores that are configured to receive
pins therein.
5. The instrument set of claim 4, wherein the pins act to inhibit
undercutting of an ACL island during the first sagittal resection
and the second sagittal resection.
6. The instrument set of claim 1, further comprising an alignment
guide with elongated arms that are configured to be slidably
located in the medial and lateral cut slots, the alignment guide
configured to aid in the positioning of the vertical cut guide
relative to the medial portion and the lateral portion of the
proximal tibia.
7. The instrument set of claim 1, further comprising a tibial
resection guide configured to couple to the vertical cut guide and
rotate relative thereto, the tibial resection guide having a stylus
configured to engage a lowest point of a medial tibial plateau.
8. The instrument set of claim 1, further comprising a locking arm
coupled to the cut guide at a location between the medial and
lateral cut slots, the locking arm movable between an unlocked
position where the vertical cut guide is permitted to translate
within the first slot and a locked position where the locking arm
engages the tibial resection block and inhibits movement of the
vertical cut guide relative to the tibial resection block.
9. The instrument set of claim 1, wherein the vertical cut guide is
configured to be adjustable relative to the tibial resection block
and is configured with a body to space the medial and lateral cut
slots relative one another to set a location for the first and
second sagittal resections that form an anterior cruciate ligament
island in the proximal tibia.
10. An instrument set for preparing a proximal tibia during a
bi-cruciate retaining procedure, the instrument set comprising: a
tibial resection block configured to be fixed to an anterior
portion of the proximal tibia, the tibial resection block defining
a first slot that continuously extends in a medial-lateral
direction from a lateral portion of the proximal tibia to a medial
portion of the proximal tibia when the tibial resection block is
fixed to the proximal tibia, the first slot configured act as a
guide for performing a proximal resection of both the medial
portion and the lateral portion of the proximal tibia; a vertical
cut guide configured to be received in and to slidably translate
along the first slot of the tibial resection block in the
medial-lateral direction, the vertical cut guide defining a bore
that communicates with a sagittal slot defined by the vertical cut
guide; a tibial tray trial having a U-shaped body portion with a
lateral side and a medial side, the tibial tray trial configured to
receive an island on a proximal tibia to preserve an anterior
cruciate ligament of the patient; a tibial tray trial insert
configured to be coupled to the tibial tray trial, wherein the
tibial tray trial insert has a medial portion configured to be
positioned on the medial portion of the proximal tibia after the
performing of the proximal resection and has a lateral portion
configured to be positioned on the lateral portion of the proximal
tibia after the performing of the proximal resection, wherein the
tibial tray trial insert has at least one of a peg or keel
configured to insert into one prepared recesses in the proximal
tibia; and a lateral tibial bearing trial and a medial tibial
bearing trial configured to couple to the tibial tray trial, the
lateral tibial bearing trial configured to couple to the lateral
side of the tibial tray trial and be disposed lateral of the island
when assembled and the medial tibial bearing trial configured to
couple to the medial side of the tibial tray trial and be disposed
medial of the island when assembled.
11. The instrument set of claim 10, wherein the sagittal slot
comprises both a medial slot for performing a first sagittal
resection of the medial portion of the proximal tibia and a lateral
slot for performing a second sagittal resection of the lateral
portion of the proximal tibia.
12. The instrument set of claim 11, wherein the bore comprises a
partial bore configured to receive a pin therein, the pin
configured to fix the vertical cut guide to the proximal tibia at
one or both of the medial portion and the lateral portion
thereof.
13. The instrument set of claim 12, wherein the pin acts to inhibit
undercutting of the island during at least a first sagittal
resection using the sagittal slot as a guide.
14. The instrument set of claim 10, wherein the vertical cut guide
is configured such that the sagittal slot is open at a proximal
surface of the vertical cut guide.
15. The instrument set of claim 10, wherein the vertical cut guide
is configured such that the sagittal slot is at least partially
closed by a wall at a proximal surface of the vertical cut
guide.
16. An instn ment set for preparing a proximal tibia during a
bi-cruciate retaining procedure, the instrument set comprising: a
tibial resection block configured to be fixed to an anterior
portion of the proximal tibia, the tibial resection block defining
a first slot that continuously extends in a medial-lateral
direction from a lateral portion of the proximal tibia to a medial
portion of the proximal tibia when the tibial resection block is
fixed to the proximal tibia, the first slot configured act as a
guide for performing a proximal resection of both the medial
portion and the lateral portion of the proximal tibia; a vertical
cut guide configured to be received in and to slidably translate
along the first slot of the tibial resection block in the
medial-lateral direction, the vertical cut guide defining a bore
that communicates with a sagittal slot defined by the vertical cut
guide, wherein the bore comprises a partial bore configured to
receive a pin therein, the pin configured to fix the vertical cut
guide to the proximal tibia at one or both of the medial portion
and the lateral portion thereof; a tibial template configured to
size the tibia, wherein the template has a handle and a U-shaped
body portion with a medial side configured to be positioned on the
medial portion of the proximal tibia after the performing of the
proximal resection and a lateral side configured to be positioned
on the lateral portion of the proximal tibia after the performing
of the proximal resection, wherein the tibial template forms one or
more of a drill guide and a passage therein; and an
anterior/posterior sizer having a locator pin extending from a
posterior end portion thereof wherein the anterior/posterior sizer
is configured to position the locator pin at a posterior edge of
the tibia and has indicia along an anterior portion thereof.
17. The instrument set of claim 16, wherein the pin acts to inhibit
undercutting of an ACL island during at least a first sagittal
resection using the vertical cut guide.
18. The instrument set of claim 16, wherein the vertical cut guide
is configured such that the sagittal slot is open at a proximal
surface of the vertical cut guide.
19. The instrument set of claim 16, wherein the vertical cut guide
is configured such that the sagittal slot is at least partially
closed by a wall at a proximal surface of the vertical cut guide.
Description
FIELD
The following disclosure recites generally to knee surgery and more
specifically to instrumentation, implants, and related method for
preparing a knee for a bi-cruciate knee implant.
SUMMARY
This section provides a general summary of the disclosure, and is
not a comprehensive disclosure of its full scope or all of its
features.
An instrument set for preparing a proximal tibia during a
bi-cruciate retaining procedure can include a tibial resection
block, a vertical cut guide, and a locking arm. The tibial
resection block can be configured to be fixed to an anterior
portion of the proximal tibia. The tibial resection block can
define a slot that extends in a medial-lateral direction when the
tibial resection block is fixed to the proximal tibia. The vertical
cut guide can have a body, a medial arm, and a lateral arm. A
medial cut slot can be defined between the body and the medial arm.
A lateral cut slot can be defined between the body and the lateral
arm. The cut guide can further comprise a tongue extending
therefrom. The tongue can be configured to be received by and
slidably translate along the slot of the tibial resection block.
The locking arm can be coupled to the cut guide and be movable
between an unlocked position and a locked position. In the unlocked
position, the cut guide is permitted to translate relative to the
tibial resection block. In the unlocked position, the locking arm
can engage the tibial resection block and inhibit movement of the
cut guide relative to the tibial resection block.
According to additional features, the locking arm can rotate
relative to the cut guide between the unlocked and locked
positions. The locking arm can comprise a finger that extends
therefrom and that engages the tibial resection block in the locked
position. The body of the cut guide can be open at the medial and
lateral cut slots. The medial and lateral cut slots can terminate
at partial bores that are configured to receive pins thereat. The
body of the cut guide can have upper medial and lateral walls. The
instrument set can further comprise an alignment guide having
elongated arms configured to locate on opposite sides of the cut
guide body. The instrument set can additionally comprise a tibial
resection guide having a stylus configured to engage a lowest point
of a medial tibial plateau.
A method for preparing a proximal tibia for receipt of a
bi-cruciate implant can include determining a resection level of
the proximal tibia. A tibial cut block can be fixed relative to the
proximal tibia based on the determination. A vertical cut guide can
slidably translate along a slot defined in the tibial cut block
until a desired medial-lateral position relative to the proximal
tibia has been attained. The vertical cut guide can be fixed
relative to the tibial cut block based on attaining the desired
medial-lateral position. A vertical medial cut can be prepared into
the proximal tibia while referencing a medial slot defined in the
vertical cut guide. A vertical lateral cut can be prepared into the
proximal tibia while referencing a lateral slot defined in the
vertical cut guide.
According to additional features, the method can further include
locating a tongue extending from the vertical cut block into the
slot of the tibial cut block. A locking arm extending from the
vertical cut guide can be moved from an unlocked position to a
locked position. In the locked position, a finger can extend from
the arm that engages the tibial cut block. The locking arm can be
rotated relative to the vertical cut guide from the unlocked
position to the locked position. A medial side of the proximal
tibia can be horizontally resected. A spacer can be positioned onto
the resected medial side of the proximal tibia. A medial side gap
can be verified. A lateral side of the proximal tibia can be
horizontally resected. A spacer can be positioned onto the resected
lateral side of the proximal tibia. A lateral side gap can then be
verified. At least one pin can be advanced through a bore defined
in the vertical cut guide and into the proximal tibia. The pin can
be referenced during the preparation of the vertical, medial, and
lateral cuts. The pin can inhibit undercutting of an ACL
island.
According to other features, anterior tibial bone can be removed
subsequent to preparing the horizontal medial and lateral side
resections. The proximal tibia can be sized by locating a tibial
template onto the proximal tibia. The tibial template can have a
U-shaped body, a medial and lateral passage, and a medial and
lateral cut guide. Anterior holes can be prepared into the tibia
while referencing the medial and lateral drill guides on the tibial
template. Keel holes can be prepared into the tibia while
referencing the medial and lateral passages on the tibial template.
A tibial tray trial insert connected to the tibial tray trial can
be positioned onto the proximal tibia. Pegs extending from the
trial insert can be located into the anterior holes. Keels
extending from the trial insert can be located into the keel
holes.
Further areas of applicability will become apparent from the
description provided herein. The description and specific examples
in this summary are intended for purposes of illustration only and
are not intended to limit the scope of the present disclosure.
DRAWINGS
The drawings described herein are for illustrative purposes only of
selected embodiments and not all possible implementations, and are
not intended to limit the scope of the present disclosure.
FIGS. 1-37 illustrate tibial preparation according to one example
of the present teachings.
FIG. 1 is a perspective view of an exemplary 4-in-1 cutting block
shown with a selectively attachable ACL protector.
FIG. 2 is a perspective view of the 4-in-1 block of FIG. 1.
FIG. 3 is an anterior view of an exemplary tibia shown prior to
performing tibial preparation.
FIG. 4 is an anterior view of the tibia of FIG. 3 and shown
subsequent to the tibial preparation.
FIG. 5 is an anterior perspective view of the tibia shown with an
extramedullary tibial resection guide attached thereto.
FIG. 6 is an anterior perspective view of the proximal tibia and
shown with a tibial resection block coupled to the extramedullary
tibial resection guide and located against the proximal tibia.
FIG. 7 is a medial perspective view of the proximal tibia of FIG. 8
shown with a terminal end of a modular stylus engaged to the lowest
point of the medial tibial plateau.
FIG. 8 is an anterior perspective view of the proximal tibia shown
with the modular stylus positioned with a terminal end of the
modular stylus engaged to the lowest point of the medial tibial
plateau.
FIG. 9 is an anterior perspective view of the proximal tibia of
FIG. 8 shown with the tibial resection block coupled with a modular
stylus being adjusted to a desired location.
FIG. 10 is an anterior perspective view of the proximal tibia shown
with a vertical cut guide coupled to the tibial resection block in
line with an ACL and tibial island.
FIG. 11 is an anterior view of the tibia of FIG. 10 and shown with
the vertical cut guide coupled to the tibial resection block in a
locked position.
FIG. 12 is an anterior view of the proximal tibia shown subsequent
to performing a pair of vertical cuts that will form lateral and
medial sides of an ACL island made while referencing the vertical
cut guide.
FIG. 13 is a superior view of the proximal tibia shown with a
pre-trial spacer located atop of the lateral plateau to verify the
height of tibial bone that was resected.
FIG. 14 is an anterior perspective view of the proximal tibia and
pre-trial spacer shown in FIG. 13.
FIG. 15 is a superior view of the proximal tibia shown with a
Rongeur tool initially located for resection of the anterior
portion of the tibia.
FIG. 16 is a close-up view of the anterior portion of the ACL
island of FIG. 15.
FIG. 17 is an anterior perspective view of the proximal tibia of
FIG. 15.
FIG. 18 is an anterior perspective view of the tibia of FIG. 17 and
shown subsequent to resection of the anterior island and using a
rasp to clean up the surface surrounding the ACL island.
FIG. 19 is an anterior perspective view of the proximal tibia shown
with a tibial plateau angle gauge disposed thereon.
FIG. 20 is a close-up view of a scale of the tibial plateau angle
gauge of FIG.19.
FIG. 21 is a perspective view of a spacer tool used to verify a
medial and lateral gap.
FIG. 22 is a superior view of the proximal tibia shown using an
optional anterior/posterior sizer to verify tibia size.
FIG. 23 is a close-up view of a scale of the sizer shown in FIG.
22.
FIG. 24 is a perspective view of the proximal tibia and shown with
a tibial template and anterior/posterior sizer disposed thereon
used to verify size, rotation and slope.
FIG. 25 is a lateral view of the proximal tibia shown with the
tibial template and anterior/posterior sizer of FIG. 24 disposed
thereon.
FIG. 26 is an anterior perspective view of the proximal tibia and
shown with the tibial template placed thereon and shown with a
drill aligned for receipt by a medial anterior grill guide on the
tibial template.
FIG. 27 is an exploded front perspective view of a tibial mask and
tibial template.
FIG. 28 is an anterior perspective view of the proximal tibia and
shown with a toothbrush keel blade aligned for receipt into a
medial passage provided in the tibial template.
FIG. 29 is an anterior view of the proximal tibia of FIG. 28 and
shown with the toothbrush keel blade received by the medial passage
of the tibial template during formation of a medial groove in the
tibia.
FIG. 30 is a front perspective view of a tibial tray trial and
tibial tray trial insert constructed in accordance to one example
of the present teachings.
FIG. 31 is a front perspective view of the tibial tray trial and
tibial tray trial insert shown in an assembled position.
FIG. 32 is an anterior perspective view of the prepared proximal
tibia shown with the tibial tray trial and tibial tray trial insert
located thereon.
FIG. 33 is a medial perspective view of the proximal tibia and
shown with a tibia bearing trial handle and tibial impactor coupled
to the tibial tray trial.
FIG. 34 is an anterior perspective view of the proximal tibia of
FIG. 33 and bearing trial handle tool.
FIG. 35 is an anterior perspective view of the proximal tibia of
FIG. 34 shown with the bearing trial handle tool positioning a
bearing onto the tibial tray.
FIG. 36 is a front perspective view of the proximal tibial of FIG.
35 shown with a medial and lateral bearing coupled to the tibial
tray.
FIG. 37 is a front perspective view of the tibial tray of FIG. 36
shown with a femoral trial used to check range of motion.
Corresponding reference numerals indicate corresponding parts
throughout the several views of the drawings.
DETAILED DESCRIPTION
The following description will focus on preparation of a left knee
for receipt of a bi-cruciate knee implant. In this regard, the
following description will be directed toward various methods and
techniques using instrumentation for preparing a left knee using a
bi-cruciate knee system. It will be appreciated however, that the
same may be adapted for use with a right knee.
While the intended focus of the instant application will be
directed specifically to preparation of the tibia and related
implants, a brief description of an exemplary preparation of a left
femur will be described. In order to assess bone stock, potential
ligament instability and the anatomical axis, a standing
anterior/posterior x-ray may be used. In some examples, a 36 inch
long standing anterior/posterior x-ray may be used. Initially, the
angle between the anatomic and mechanical axis may be determined
while assuring that the distal femoral cut is perpendicular to the
mechanical axis. At this time, the femoral component size may be
estimated pre-operatively by using lateral view x-rays and radio
graphic templates. The appropriate size femoral component may be
confirmed intra-operatively.
An intramedullary (IM) drill may be used to penetrate the
intracondylar notch and dense cancellous bone of the distal femur
to a depth of approximately 1.5-2 inches (3.5-5 centimeters). A
0.375 inch drill may be used to penetrate the distal femur. The
canal entry location may be placed one centimeter above the
insertion of the posterior cruciate ligament and slightly medial in
the intracondylar notch. The appropriate left or right valgus wing
may be chosen and slid onto the IM rod. The IM rod may be
introduced into the femoral canal to de-pressurize the canal. The
valgus wing may be slid until it rests against the medial distal
condyle. The Slidex.RTM. Distal Resection Block and cut block
adapter are both slid into the anterior holes of the valgus wing
until the Slidex.RTM. Distal Resection Block contacts the anterior
cortex of the femur.
To confirm the valgus angle, the alignment handle can be inserted
into the cut block adapter and a 1/4 inch alignment rod can be
inserted and extended to the center of the femoral head. The
Slidex.RTM. Distal Resection Block can then be pinned into place
using 1/8 inch quick release drill pins in the most proximal pin
holes of the block. The valgus wing can then be removed by removing
the IM rod and pulling the valgus wing and cut block adapter
distally away from the distal resection block leaving the
Slidex.RTM. Distal Resection Block in place. Two resection slots of
0 or +3 mm are available for the distal resection. The 0 mm slot
will resect 9 mm from the most prominent part of the medial distal
condyle. If additional distal resection is required, the +3 mm slot
will resect 12 mm. If additional distal resection is required
beyond the +3 mm slot, the resection guide can be shifted
proximally by utilizing the +2 or +4 mm 1/8 inch pin holes. A 0.054
inch saw blade can be used to complete the distal resection through
the selected slot. The resected distal femur can be checked by
using a flat instrument. The bone surface may be re-cut or filed as
necessary to ensure proper resection. For additional stability, the
femoral block handle can be utilized.
An exemplary method of femoral sizing will now be described.
Initially, the adjustable anterior/posterior sizer may be placed
against the resected distal surface with the feet in contact with
the posterior condyles of the femur. In a first option, fixed
rotation feet may be used. In another option, adjustable rotation
feet may be used. An adjustable dial can be used with the
anterior/posterior sizer. The adjustable rotation feet are
available in left and right varieties with the ability to set an
external rotation from 0 to 10 degrees. In one example, it is
recommended that an initial setting of 3 degrees of rotation be
utilized. The femoral component size can now be read from the
central scale. If the size indicated is in between standard sizing
or a larger flexion gap is desired, a choice may be made to choose
the smaller size and shift the femoral 4-in-1 block placement
anteriorly. In order to shift the component anteriorly, a screw
mechanism in the central portion of the sizer is turned which
raises the level of drill holes in one millimeter increments. A
scale is located on the sizer to indicate how far the component
will be anteriorly shifted. If medial/lateral width is a concern,
the appropriately sized medial/lateral width checker can be
inserted into the anterior/posterior sizer to further evaluate the
proper size of the femur. Next, two 4-in-1 cutting block location
holes are drilled utilizing a 1/8 inch drill pin. In one example,
the final medial/lateral position of the femoral component is not
determined during this step, but is addressed later in the
technique.
With initial reference now to FIGS. 1 and 2, initial preparation of
the distal femur using a 4-in-1 block 10 according to the present
teachings will be described. At the outset, a surgeon may choose
the desired 4-in-1 block 10 that matches the selected size on the
anterior/posterior sizer and place it into the 1/8 inch holes
drilled into the distal femur. A 0.054 inch feeler blade can be
used to determine the amount of anterior bone resection. If the
feeler blade indicates a probability of notching, an
anterior/posterior femoral shift block may be used to adjust the
cut block holes anteriorly in one millimeter increments. Notably,
moving the block anteriorly will resect additional posterior
condylar bone. 1/8 inch pins can be placed in the side holes
provided on the femoral 4-in-1 block 10. The anterior/posterior
block must be sitting flush against the distal femur at this point.
An ACL protector 12 may be secured into place relative to the
4-in-1 block 10. The ACL protector 12 can be used to block the
blade from inadvertently cutting the ACL. Once the position of the
4-in-1 block 10 is satisfactory, a surgeon can resect the anterior
and posterior bone, and the anterior and posterior chamfers using a
0.054 inch saw blade. Again, care must be taken not to cut the ACL
while making the posterior and posterior chamfer boney
resections.
With reference now to FIGS. 3-37, preparation of a proximal tibia
for a bi-cruciate knee system according to a first example will be
described. FIG. 3 illustrates a tibia T1 prior to performing the
instant surgical technique. FIG. 4 illustrates a tibia T2
subsequent to performing the tibial technique according to the
present teachings. Of note, the tibia T2 includes a medial plateau
14, lateral plateau 16, anterior plateau 18, anterior chamfer wall
20, medial vertical wall 22, and lateral vertical wall 24. The
anterior chamfer wall 20, the medial vertical wall 22, and the
lateral vertical wall 24 can collectively cooperate to form an ACL
island 28. A radius 30 is formed at a transition between the medial
plateau 14 and the medial vertical wall 22. Similarly, a radius 32
is formed at a transition between the lateral plateau 16 and the
lateral vertical wall 24.
With reference now to FIGS. 5-29, resection of the tibia T will be
described. With the knee flexed, spring loaded arms 36 and 38 of an
ankle clamp 40 are located around the distal tibia T just around
the malleoli. The ankle clamp 40 can generally be attached to an
extramedullary tibial resection guide 42. The extramedullary tibial
resection guide 42 can further comprise a handle portion 44, a
telescoping rod portion 46, and a resection block connecting
portion 48. A button 50 can be provided on the extramedullary
tibial resection guide 42 that can control telescoping action of
the rod portion 46 generally from the handle portion 44.
At this point, a tibial resection block 54 (FIG. 6) can be placed
against the proximal tibia T. Returning now to FIG. 5, from the
sagittal view, the side of the extramedullary tibial resection
guide 42 is adjusted such that it is generally parallel with the
shaft of the tibia T. The tibial resection block is set at 4
degrees of slope (other measurements may be used) when attached to
the extramedullary guide. Once adjustment of the resector axis is
correct in the medial/lateral view, the resection block connecting
portion 48 is rotated until the shaft of the resector is just
medial to the tibial tubercle. Using a stylus 60 (FIGS. 7 and 8),
the extramedullary tibial resection guide 42 is adjusted such that
a terminal end 62 of the stylus 60 is engaged to a lowest point of
the medial tibial plateau 64. Using a 1/8 inch pin 66, the
extramedullary tibial resection guide 42 is secured to the tibia T.
A dial 68 may be used to fine tune the resection level prior to
making any cut (FIG. 9).
Of note, the stylus 60 is set for a 4 mm resection. Prior to
pinning the extramedullary tibial resection guide 42 in place, make
sure to allow for adjustability of the height of a tibial resection
cut block 70. The tibial resection block 70 can define a horizontal
slot 71. Once the resection level is set, the stylus 60 can be
removed. A vertical cut guide 72 can then be attached to the tibial
resection block 70 (FIG. 10).
The vertical cut guide 72 can then be adjusted to an appropriate
position (in a medial/lateral direction along the slot 71) to make
the desired vertical cuts. Specifically, a tongue 72a extending
from the vertical cut guide 72 can slide along the slot 71. An
alignment guide 73 can be used to aid in the positioning of the
vertical cut guide 72. The alignment guide 73 generally includes a
pair of parallel and elongated arms 73a that slidably locate on
opposite sides of the vertical cut guide 72. Of note, the vertical
cuts will determine the final tibial component rotation. It is
important to leave equal amounts of bone on the medial and lateral
aspect of the ACL fibers. At this point, the vertical cut guide 72
can be clamped in place by rotating a locking arm 72b from an
unlocked position shown in FIG. 10 to a locked position shown in
FIGS. 11 and 12. In one example, the locking arm 72b can have a
finger 72c that rotates into fixed engagement with an upper surface
72d of the cut block 70. With a reciprocating saw, a vertical
medial cut 74 can be prepared while passing a saw through a medial
slot 75a defined between a main body 75b of the vertical cut guide
72 and a medial arm 75c. The vertical medial cut 74 may be prepared
while referencing a medial surface 75 of the vertical cut guide 72.
It will be appreciated that the vertical medial cut 74 may be
prepared while concurrently referencing the medial arm 75c. After
the vertical medial cut 74 has been prepared, the vertical lateral
cut may be made. The vertical lateral cut 76 can be prepared while
passing a saw through a lateral slot 77a defined between the main
body 75b of the vertical cut guide 72 and a lateral arm 77c. The
vertical lateral cut 76 may be prepared while referencing a lateral
surface 77 of the vertical cut guide 72. It will be appreciated
that the vertical lateral cut 76 may be prepared while concurrently
referencing the lateral arm 77c. Headless vertical pins 78 can be
located through partial bores 79 (FIGS. 11 and 12) provided in the
vertical cut guide 72 driven into the anterior tibia T. The
vertical medial cut 74 and the vertical lateral cut 76 can both be
prepared using a saw blade having teeth or cutting structure
consistent for forming the radius cuts 30 and 32 identified in FIG.
4. Notably, by incorporating a radius at this transition, the bone
at the transition between the respective medial and lateral
plateaus 14, 16 and ACL island 28 (FIG. 4) can be stronger as
compared to a transverse, 90 degree intersecting cut. Next, the
vertical cut guide 72 is removed from the headless vertical pins
78. The medial side of the tibia T may then be horizontally
resected.
With reference to FIG. 12A, a cross-sectional view of the cut guide
72 is shown. FIGS. 12B and 12C show an alternate vertical cut guide
72'. Unless otherwise described herein, the cut guide 72'
incorporates similar features as the cut guide 72 that are
identified with like reference numerals having a prime suffix. The
cut guide 72' provides a captured vertical medial slot 75a' and a
captured vertical lateral slot 77a'. Specifically, an upper medial
wall 80 and an upper lateral wall 82 close the respective vertical
medial slot 75a' and the vertical lateral slot 77a'. The upper
medial and lateral walls 80 and 82 can assist in maintaining a saw
blade within the respective medial and lateral slots 75a' and
77a'.
At this point, the medial side gap may be verified in extension
using an 8/9 mm spacer block 100 (FIGS. 13-14). If the 9 mm spacer
portion 102 is too tight, additional tibial bone will need to be
removed. This can be done by simply dialing the resection block
down 1 mm. Once the medial side extension gap is adequate, the
lateral side of the tibia T is horizontally resected with the
headless vertical pins 78 left in place. The headless vertical pins
78 protect against undercutting the ACL island 28.
As illustrated in FIGS. 15-17, a Rongeur tool 108 can be used to
remove the anterior bone making sure to round the corners of the
anterior island. Next, an ACL island rasp 120 (FIG. 18) is used to
clean the resected tibia T to ensure that there are no rough edges
around the ACL island 28 and respective medial and lateral plateaus
14 and 16. Using the tibial plateau angle gauge 130 (FIG. 19), the
tibial slope cuts are verified to have an equal amount of slope.
This will be important for the tibial base plate to be secured
properly, and for the proper wear and function of the system.
Turning now to FIG. 21, tibial sizing for an intact and functional
ACL will be described. The medial and lateral gaps are verified
using a spacer tool 140. A series of 1 mm spacers 142 may be
magnetically coupled as needed. Rotation and slope may also be
verified. Optionally, the tibia T may be sized with an
anterior/posterior sizer 143 (FIGS. 22 and 23).
The tibia T may then be sized with a tibial template 144 (FIGS.
24-25). The tibial template 144 generally comprises a U-shaped body
portion 146 having a lateral side 148, and a medial side 150. A
lateral passage 152 and a lateral anterior drill guide 154 can be
provided on the lateral side 148. Similarly, a medial passage 162
and medial anterior drill guide 164 can be provided on the medial
side 150. Because rotation is determined by the position of the ACL
island 28, it is important to check for accurate rotation. Base
rotation can be made relative to the tibial tubercle and the
malleolar axis. At this point, an extramedullary alignment check
can be made by placing a 1/4 inch alignment rod through a handle
170 of the tibial template 144. Slight external rotation is
preferred to optimize patellofemoral tracking. Once the final
rotation has been determined, the position can be marked by
extending anterior marks of the tibial template 144 onto the
anterior tibia such as by electrocautery. A locator pin 173
extending from the anterior/posterior sizer 143 can be located
around the posterior edge of the tibia T. Extra caution should be
used to avoid internal rotation of the tibial template 144 due to
the presence of lateral soft tissue.
Tibial preparation for an intact and functional ACL will now be
described. With the tibial template 144 in proper position (FIG.
26), such as by way of pins 174, a drill 175 can be used to prepare
an anterior hole while referencing the lateral anterior drill guide
154. A tibial mask 176 may be coupled to the tibial template 144.
In one example, a 1/8 inch drill 175 may be used (FIG. 26). Next,
another anterior hole can be drilled with the drill 175 while
referencing the medial anterior drill guide 164.
With the tibial template 144 secured in place, a toothbrush keel
blade 190 can be used to prepare both the medial and lateral tibia
for the keeled base plate. Specifically, the toothbrush keel blade
190 can be inserted through the lateral passage 152 and the medial
passage 162 (FIGS. 28 and 29). While the tibia T is being prepared,
the tibial trial assembly 200 (FIGS. 30 and 31) can be prepared.
The tibial trial assembly 200 can include a tibial tray trial 202
and tibial tray trial insert 204. Once tibial preparation is
complete, the tibial template 144 can be removed from the proximal
tibia. The tibial tray trial 202 can have multiple versions that
provide various dimensions. Similarly, the tibial tray trial insert
204 can also provide various dimensions suitable for the needs of a
particular patient. Of note, the tibial tray trial insert 204
includes pegs 210 and keels 213. The pegs 210 have a spacing that
corresponds to the passages made earlier with the drill 175.
Similarly, the keels 213 have dimensions suitable for insertion
into the grooves prepared with the toothbrush keel blade 190. As
illustrated in FIG. 33, a tibial tray trial 202 is shown being
impacted onto the tibia T using a tibial impactor 232. As
illustrated in FIGS. 34-36, a lateral tibial bearing trial 224 and
a medial tibial bearing trial 226 can be coupled to the tibial tray
trial 202 using a bearing trial handle tool 228 and trialed. Also,
the tibial tray trial 202 can be positioned with the bearing trial
handle tool 228 (FIG. 34). As shown in FIG. 37, a femoral trial 240
can be used to verify range of motion.
The foregoing description of the embodiments has been provided for
purposes of illustration and description. It is not intended to be
exhaustive or to limit the disclosure. Individual elements or
features of a particular embodiment are generally not limited to
that particular embodiment, but, where applicable, are
interchangeable and can be used in a selected embodiment, even if
not specifically shown or described. The same may also be varied in
many ways. Such variations are not to be regarded as a departure
from the disclosure, and all such modifications are intended to be
included within the scope of the disclosure.
* * * * *